Report Date


Case Against

A GP Practice in the area of Betsi Cadwaladr University Health Board


Clinical treatment outside hospital; GP

Case Reference Number



Upheld in whole or in part

Mr B’s family complained about the care provided to him by his GP practice and whether there was a failure to appropriately manage his Chronic Obstructive Pulmonary Disease (“COPD” – a long term lung condition) between March 2021 and August 2022. Specifically, whether Mr B’s medication was appropriately managed; whether referrals from other health professionals (including Pharmacists) were acted upon; whether appropriate reviews were undertaken; whether appropriate referrals were made, and; whether Mr B’s treatment plan was appropriate(including whether weight management should have formed part of the plan).

The Ombudsman found that the care provided to Mr B by the Practice between March 2021 and August 2022 was acceptable and that his COPD was appropriately managed during this period. The Ombudsman did not uphold the first 4 complaints. The Ombudsman also found that Mr B’s treatment plan was acceptable overall. However, there was a missed opportunity for Mr B’s weight to be noted at the COPD therapy review on 23 June 2022 and, although there was no specific indication of detriment to Mr B or that the outcome would have been any different, this uncertainty was an injustice to Mr B. To that limited extent only, this element of the fifth complaint was upheld.

The Ombudsman recommended that the Practice should write to Mr B’s family with an apology for the failing identified in the investigation. She also recommended that the Practice complete an audit of a random sample of COPD reviews conducted since 2023 to determine whether weight/BMI is being recorded and that appropriate dietician referrals or other action is taken, if indicated/required.